A 14-year-old female presents to the clinic for her annual physical examination. The setting is a private examination room with a table, chair, and medical equipment. The encounter is a routine physical examination to assess the client’s growth, development, and overall health status
The Client’s Challenging Behaviors
The client appears hesitant and unwilling to answer questions about her health history and lifestyle habits during the encounter. She avoids eye contact, responds with short answers, and appears anxious and fidgety. She becomes visibly uncomfortable and shuts down when asked about her menstrual cycle.
Potential Impact on Client-Provider Relationship
The client’s reluctance to answer questions can hinder establishing a trusting and collaborative relationship between the NP and the client. It may also impede the NP’s ability to accurately assess the client’s health needs and provide appropriate care. The client may feel uncomfortable, embarrassed, or judged, leading to decreased satisfaction with the encounter and reluctance to seek medical care in the future.
Techniques to Enhance Communication
To address the client’s behavior, the NP can use the following techniques: build rapport and establish trust by being non-judgmental, respectful, and empathetic. The NP should use open-ended questions to encourage the client to share her thoughts and feelings (Grunfeld & Hunter, 2021). Another technique is providing assurance of confidentiality and privacy to increase the client’s comfort level. Moreover, the NP should use age-appropriate language and avoid medical jargon to enhance the client’s understanding. Besides, the NP should validate the client’s concerns and emotions and reassure her that the encounter is a safe space to discuss health-related issues (Lindström & Markström, 2020). Finally, the NP should use a trauma-informed approach to understand and address the client’s anxieties or fears.
Sample Documentation
Subjective
The client is a 14-year-old female presenting for a routine physical examination. The client appeared hesitant and uncomfortable during the encounter, particularly when asked about her menstrual cycle. She was reluctant to share her health history and lifestyle information.
Objective
The client is a healthy-appearing adolescent female, well-groomed and alert. Vital signs are within normal limits. Physical examination findings are unremarkable.
Assessment
The client exhibited reluctance and hesitancy during the encounter, indicating possible anxiety or discomfort with discussing health-related topics.
Plan
The NP used a trauma-informed approach to address the client’s behavior and built rapport by being non-judgmental, respectful, and empathetic. The NP used open-ended questions, provided assurance of confidentiality, and validated the client’s concerns and emotions (Rand et al., 2019). The encounter was concluded with recommendations for follow-up care and a plan for future health promotion activities.
References
Grunfeld, E., & Hunter, L. (2021). Communication challenges in adolescent healthcare: A scoping review. International Journal of Adolescent Medicine and Health,